8/21- Pericardial Diseases Flashcards

1
Q

What are the layers of the pericardium?

A
  • Fibrous (mostly acellular)
  • Serous: parietal layer
  • Serous: visceral layer (epicardium)

Pericardial cavity is between the parietal and visceral portions of the serous pericardium; normally ~50cc of fluid

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2
Q

What are the 4 basic functions of the pericardium?

A
  1. Restraining effect on cardiac volume
  2. Maintain optimal P-V relationships in the cardiac chambers
  3. Favor ejection of similar stroke volumes for both ventricles
  4. Shield heart against infections from contagious structures
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3
Q

What is a pericardial effusion?

A

The buildup of fluid within the pericardial space

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4
Q

What are some causes of pericardial effusions?

A
  • Idiopathic (most common)
  • Infectious; viral, bacterial, mycobacteria, fungal, protozoal
  • Immune/inflammatory: CT disease, arteritis, inflammatory bowel disease, early/late post-MI, drug induced
  • Neoplastic disease
  • Radiation
  • Thyroid disease
  • ESRD (end stage renal disease)
  • Early post cardiac surgery
  • Trauma
  • Congenital (e.g. born without pericardium)
  • Hemopericardium: trauma, post MI free wall rupture, device or procedure related, dissecting aortic aneurysm
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5
Q

What is cardiac tamponade?

What determines the hemodynamic consequences?

A
  • Reduces the volume of the cardiac chambers such that cardiac output begins to decline
  • Continuation from an effusion causing minimally detectable effects to full-blown circulatory collapse

Hemodynamic consequences determined by:

- Intrapericardial pressure

  • Ability of the heart to compensate for elevated pressure
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6
Q

What is the body’s compensatory response to cardiac tampanode/rapidly accumulating pericardial fluid?

A
  • Increased adrenergic stimulation and PS withdrawal (tachycardia and increased contractility); done to maintain CO
  • In terminal stages: depressive reflex = paradoxical bradycardia (about to code)
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7
Q

Hemodynamics of cardiac tamponade?

A
  • Abrupt rise of pericardial pressure
  • Rise of atrial and ventricular diastolic pressures (intracardiac pressures)
  • Equalization of intracardiac pressures (not normal)

- Loss of y-descent

- Pulsus paradoxus

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8
Q

Describe the negative components of the atrial pressure waveform?

What can indicate pathology?

A

x-descent: seen when atria are actively relaxing; ventricular contraction

y-descent: occurs during ventricular systole

  • blunted in cardiac tamponade because of constriction by pericardial fluid
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9
Q

What is shown here?

A

Pulsus paradoxus

  • “exaggerated inspiratory drop in SBP > 10 mmHg”
  • Hallmark of cardiac tamponade!

(Variation in systemic blood pressure and pulse due to constriction by pericardial fluid of the heart)

  • Filling of the L and R sides of the heart become dependent on each other (not normal)- “intra-ventricular dependence”
  • During inspiration, negative pressure typically helps right side of the heart fill; in tamponade, filling of the R causes septum to bulge into L side of the heart and decreases SV and CO of L side

(IV shift into LV -> reduced LV EDV -> SV decreases (Frank-Starling law) -> SBP decreases)

- See decrease in BP and pulse during inspiration in cardiac tamponade

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10
Q

Symptoms and PE of cardiac tamponade?

A
  • Pericardial chest pain

- Dyspnea/tachypnea**

  • Shock
  • Non-specific sense of discomfort (generalized malaise)
  • Tachycardia
  • Pulsus paradoxus
  • Beck’s triad: hypotension, muffled heart sounds (due to fluid), elevated JVP (normal decrease on inspiration)
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11
Q

Is pulsus paradoxus always present in cardiac tamponade?

A

No

  • Severe hypotension of hypovolemia prevents the rise in RV filling in inspiration
  • Volume replacement often facilitates its detection
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12
Q

What is seen here?

A

Typical of cardiac tamponade/pericardial effusion

- “Electrical alternans”

  • QRS varying with every other beat of the heart (due to swinging of heart with large pericardial fluid)
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13
Q

What is seen here?

A

CXR of pericardial effusion

  • Very large, globular heart
  • Typically, heart borders should be less than half the thoracic cavity distance
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14
Q

What is seen here?

A

Pericardial effusion by echo (diagnostic)

  • Dark area on left (blood/fluid) is in the pericardial space
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15
Q

What is constrictive pericarditis?

A
  • Impairment of diastolic filling due to chronic thickening and/or calcification of the pericardium
  • Typically a chronic process (where cardiac tamponade was more acute)
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16
Q

Etiology of constrictive pericarditis (causes)?

A
  • Idiopathic (most frequent)
  • Infectious: bacterial (TB!, staph aureus, pneumococcus…), viral, fungal, lparasitic
  • Irradiation (for Hodgkin’s disease or other chest malignancies)
  • CT disease: RA, SLE
  • Post-hemopericardium (post-op, trauma)
  • Uremia (ESRD)
  • Neoplastic
17
Q

What is seen here?

A

CXR and CT of constrictive pericarditis with extensive pericardial calcification

  • Will see rim (light segment), which is the pericardium filled with calcium
  • “Thick bright rim of calcified pericardium”
18
Q

What is seen here?

A

Chest CT form pt with pericardial constriction showing thickened pericardium (arrows) and a left pleural effusion(*)

19
Q

Pathophysiology of constrictive pericarditis?

A
  • Impaired diastolic filling (due to thickening of pericardium)
  • Elevation of LV diastolic pressure
  • Elevation of atrial pressure
  • Equalization of elevated IC pressure

(These are also characteristics of cardicac tamponade)

20
Q

What are the PE findings in constrictive pericarditis?

A
  • Present with CHF signs: dependent edema, hepatomegaly, ascites, and JVD
  • JVP: elevated with steep y-descent

- Small quiet heart and clear lungs

  • Kussmaul sign
  • Pericardial knock extra sound
21
Q

What is Kussmaul sign?

A
  • More prominent neck veins during inspiration
  • Distended neck veins that do NOT collapse with inspiration
22
Q

What is a pericardial knock?

A
  • Early diastolic extra sound (K)
  • Occurs shortly after S2
  • Results from abrupt cessation or slowing of ventricular filling as the stiff pericardium limits expansion of the ventricle
  • May be confused with an S3 gallop
23
Q

How is constrictive pericarditis diagnosed?

A

Right heart catheterization with dip-and-plateau RV pressure

24
Q

What causes a steep y descent (JVP) and dip-and-plateau (RVP) in constrictive pericarditis?

Why NOT in cardiac tamponade?

A

In constrictive pericarditis, enhanced early RV filling leads to:

  • Rapid RA emptying >> steep Y descent
  • Rapid RV filling >> “dip” in RVP

Cardiac tamponade is a pan-diastolic impairment of RV/LV filling; NO enhanced early filling

  • NO early diastolic steep descent (in fact, y-descent is blunted)
  • NO early diastolic “dip” in RVP
25
Q

What characteristics are responsible for the dip-and-plateau RVP in constrictive pericarditis?

A
  • Enhanced early RV filling -> “dip”
  • Reduced late RV filling -> “plateau”
26
Q

What is the clincial triad of constrictive pericarditis?

A
  1. Congestive heart failure signs and symptoms
  2. Prominent Y descent in the neck veins
  3. Small quiet heart
27
Q

Compare and contrast cardiac tamponade and constrictive pericarditis

  • Filling
  • Heart sounds
  • Observed in JVP/cath
A
28
Q

What is the treatment for cardiac tamponade?

A

Pericardiocentesis- pericardial tap to remove pericardial fluid; may insert drain

  • Considered a medical emergency (person about to go into shot)
29
Q

What is the treatment for constrictive pericarditis?

A

Pericardiectomy- surgical resection of the thickened pericardium

30
Q

Key points of pericardial diseases:

  • What is the major determinant of cardiac tamponade?
A

Rate of rise in pericardial pressure (NOT AMOUNT of fluid)

  • Determines how much pericardium can accommodate the fluid
31
Q

Is pulsus paradoxus a hallmark of cardiac tamponade or constrictive pericarditis?

A

Pericardial tamponade

32
Q

Is a pericardial knock a hallmark of cardiac tamponade or constrictive pericarditis?

A

Constrictive pericarditis